The National Health Service has introduced a new policy entitled 'Never Events', phased in from April 2009, throughout the whole of England. This is following on from a recent report 'High Quality Care for all' published by the Department of Health in June 2008, which suggested that a new policy should be introduced surrounding how Primary Care Trusts (PCTs) deal with these events.
These events are defined as serious patient safety incidents that are considered to be largely preventable and that should not occur if the correct measures and safety recommendations had been followed by the healthcare providers. In particular, the PCTs should now monitor the occurrence of Never Events within the services they commission. They will also have to publicly report these on an annual basis. The idea is that the policy builds on existing local and national processes for the reporting of serious incidents.
It is hoped that the new policy will increase transparency and accountability and increase patient safety in relation to serious, preventable and costly incidents. It has been designed to increase the effectiveness of the particular organisations by increasing their duties of reporting and making sure that they have the correct systems in place to prevent recurrence of such incidents.
Specific national guidance and safety recommendations are available to prevent each of the Never Events from occurring. Both providers and commissioners should assure themselves that they are aware of the guidance, and that it has been implemented.
The National Patient Safety Agency (NPSA) has produced a core list of Never Events for adopting during 2009/2010 which are outlined below
Wrong site surgery
This is where surgery is performed on the wrong site, and the error is only identified after the operation. As a result, further surgery is required to rectify the problem. In some circumstances complications can develop after the initial surgical error.
Retained instrument post-operation
This is in circumstances where one or more instruments are unintentionally left inside the body following an operative procedure. A further operation or other invasive procedure is then required to remove this. There may also be complications to the patient arising from the instrument's continued presence.
Wrong route administration of chemotherapy
There are several routes for administering chemotherapy, ie intra-muscularly, orally, via a lumbar puncture or via a vein. Giving the right chemotherapy via the wrong route can prove fatal in certain circumstances.
Misplaced naso or orogastric tube not detected prior to use
This is where a naso or orogastric tube is placed in the respiratory tract rather than the gastrointestinal tract and not detected prior to commencing feeding or other use.
Inpatient suicide using non-collapsible rails
This is in relation to suicide by a patient in an acute mental health setting using curtain or shower rails.
Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners
This refers to a patient who is a transferred prisoner escaping from a medium or high secure mental health service where they have been placed for treatment on a Home Office restriction order.
In-hospital maternal death from post-partum haemorrhage after elective caesarean section
This is in-hospital death of a mother as a result of a bleeding following elective caesarean section, excluding cases where imaging has identified problems with the placenta which render it difficult to remove (placenta accrete).
Intravenous administration of mis-selected concentrated potassium chloride
Potassium chloride is a highly toxic treatment that can prove fatal. Most of the time it is not clinically possible to reverse the effects of an incorrect treatment and for that reason utmost care must be taken in administering this treatment.
It is hoped that the guidance and changes will see a real change in the way that these events are dealt with in the future in order to increase patient safety and a subsequent reduction of preventable incidents. Further information can be found at www.npsa.nhs.uk. The website also illustrates the specific guidance in relation to each of the events listed above.
